Thursday, October 08, 2009

Getting There--To The End Of My Journey--This Time Around

Day 0, Tuesday, 15 Sep
Armed with the guarantee of payment from my insurance, I got myself admitted to Mount Elizabeth Hospital. A friendly Filipino, named Rod, seated me, asked for my passport, and checked the room reservations list. He said a single room was booked for me by my doctor’s clinic. He looked up my file and then went away for a while. Coming back, he had his own copy of the letter from my company’s insurance and a one-pager estimate of the hospitalization costs, excluding doctors’ fees, as he pointed out. I glossed it over, I was sure it was going to be taken care of by the insurance, except for lodger fees which were on top of the cost of a single room.

In a short while, we were escorted to Ward 6. Two nurses helped me settle in, one of whom was Irene, a Filipina. My husband, Let, and I marveled at the room appointments. It was huge, carpeted, with a new-looking Hill-Rom hospital bed and a huge sofa bed. The room was one grade lower than what I was entitled to, making us wonder what the single deluxe room looked like.

After settling in, a pathology staff came and took 4 tabs of blood. Afterwards, I went for the pre-surgery tests such as chest X-Ray and ECG.

Day One, Wednesday, 16 Sep
I was offered a sleeping pill the night before the surgery in case I was too tensed to sleep. But I did manage to doze off without taking the drug. It was a repeat surgery after all, and the operation, as explained by the neurosurgeon, would be simpler than the first one I had—no cut on the inner mouth would be done as he would only access the pituitary gland through my nostrils.

The operation was set for 9:30am. By three quarters past 9, an Indian lady fetched me from my room. When she came in, I asked why it was rather early, but she dismissed my question and asked me to change into the hospital gown. I did so, taking my time as I reluctantly got into the oversized blue gown which ties at the back. By this time, I was feeling a bit nervous. Good thing there was no chance to drum up my anxiety as I was fetched early. I got into the wheelchair, and glanced up to Let. Now, he was the one looking more worried as all he could muster was “Bye.” and “Kita na lang.” (See you.), as I was being wheeled out of the room.

I was then made to wait beside another patient in a stretcher in the waiting room near the Operating Theater, OT, (that’s how they call the OR). An Indian nurse came over with my folder and asked the usual pre-operation questions. Like the other Indian nurses who attended to me while I was in the ward, this one also appeared aggressive as she stood at the foot of the stretcher, leaning over my feet quite heavily and jotting down my responses.

Five minutes to nine, I was fetched by the anesthetist, a lady doctor in her fifties but with an air of youth around her, and was wheeled into the OT. She helped curb my tension as she tried to strike up a small chat asking me of what I do in the Philippines, and what the political situation was back home. I smiled at her when she asked me whether I was rooting for Aquino (Noynoy). “There is so much possibility to do good,” she said. I agreed. This exchange happened as she was inserting the drip. In the meantime, my neurosurgeon had all the scans up on the white screen and the big machine fixed on me. Then, in a snap I went out.

Four and a half hours later, I woke up to a headache inside the Critical Care Unit (CCU or ICU as it’s more commonly called). I was still very drowsy but managed to listen to the anesthetist as she relayed me the good news that they saw the tumor and Dr. Ho, the neurosurgeon, was able to remove it. I said, “Thank you.” I was still feeling heady from the drugs—anaesthesia and morphine. I have a faint memory of talking briefly to Dr. Ho, hearing him tell me that he believed that he had cured me. And then I sensed Dr. Peter Eng, my endocrinologist, hovering around me, giving instructions to the nurse. The nurse then inserted a catheter.

I again drowsed off, and woke up half past 5pm looking for my husband. The nurse called him in from the waiting area. I was already fully awake. Let came in, grasped my right hand, and gently kissed it. It was a beautiful moment. I felt God’s hand over us. It was too good, too beautiful to awaken to a loved one whose eyes showed so much gratefulness. I was happy. It was my birthday. And I was truly happy notwithstanding the physical pain from the surgery.

After a while, Dr. Ho entered the room to officially break to us the good news. He said that the operation was successful but it took more than 4 hours, as it took him 2 hours to get in and locate where my pituitary gland was. He explained that the scar from the previous operation modified how my pituitary anatomy looked, making it difficult to say which was which. According to him, he almost gave up and would have abandoned the operation if he still was not able decipher on which part the tumor was excised.

After 2 hours, he finally located the scar from a very small opening through which my first neurosurgeon accessed the gland. Once inside, he related that he then found a yellowish tissue on the right distinct from the normal gland which had a pinkish hue. Further, there was a suspicious-looking mass on the left side, which he also removed.

Dr. Ho has done quite a number of transphenoidal surgeries. He explained to me, during my first consult at his clinic, that he chooses to be more aggressive in his methods as he would rather excise a part of the normal gland than risk having a residual tumor missing his curettes. Apart from the normal procedure of scraping the tumor, he uses 100% alcohol to ensure that he kills all the undesirable tissue around the gland—a procedure not done by other neurosurgeons, but which, he said, works well for his patients based on his observation.

Dr. Ho is already in his 60s. But, to me, he looks much younger than his age, appearing still in the prime of health. He has a very good command of English, and is able to explain in great detail the procedure, mentioning his experience with patients with the same case. He mentioned that he had a patient, who happened to be a medical doctor as well, who was diagnosed with acromegaly based solely on his blood chemistry as there was no evident tumor that could be found on his MRI scans. The second time that he performed the operation on this doctor-patient of his, he was also at a loss in identifying which was the pituitary gland, and rather than create more damage, he closed him up, and abandoned the operation. He had to be aided by an MRI imaging the third time around. Needless to say, the operation was successful and the doctor, he said, so far is doing well in remission.

Day Two, Thursday, 17 Sep
Thanks to the morphine drip, I managed to get some sleep in the CCU. I had Leonie, a Filipina nurse attend to me from 10 pm to 8 am. She closely monitored my BP as the machine would frequently alarm when it dipped to around 85/45.

At 8am, Leonie endorsed my case to Furong, an equally competent and caring Chinese nurse. Furong offered me fish congee, Milo, and orange juice for breakfast. The doctor said I could eat anything. But I had no appetite. The surgery had temporarily affected my sense of smell, hence, making even the most delicious foods taste bland.

Dr. Eng, my endocrinologist, came and looked at my stats. I asked if my BP was alright. He said it was okay as my BP had always been on the low end, and the surgery had caused it to drop a bit. He ordered for hydrocortisone (cortisol/steroid) injections explaining that it is commonly given after a pituitary surgery to aid the body in recovering. I was also given Panadol (Paracetamol). He ordered for the morphine drip to be stopped. I was okay, the headache I had was mild.

Furong then arranged for my transfer to the ward. After securing a room, she removed my catheter, unhooked me from the monitors, put me in a wheel chair, and brought me to Ward 10 (Royal/Exec. Suites). I was surprised to learn that all single deluxe rooms were housed amongst the suites which accommodate the royalty and big personalities. I also did not realize that this would later on put me in a battle with the hospital’s billing dept. which would refuse to be convinced that my insurance was going to cover my “deluxe” accommodation.

Day Three, Friday, 18 Sep
Dr. Ho came early, and without any ado, motioned for the nurse to assist him as he pulled out the nasal packing. Out it went in a snap! Some blood dripped. The nurse plastered on some gauze to my nose to catch the dripping blood. I thought I’d be able to finally breathe through my nose again! But alas, my nose was heavy with mucous. I could somehow breathe from the left opening but the right side was totally blocked.

During the night, sleep would not come. The sleeplessness I would experience in the next days had then started. I could not doze off without a sleeping tablet. No matter what position I took, no matter how tired and drowsy I felt I was, I just could not completely snooze!

Day Four, Saturday, 19 Sep
I was feeling better except for the blocked nose. I was no longer getting a headache. And I was enjoying the food being served by the butler although I could hardly taste it. Yep, the room accommodation made for a royal hospital stay. There was a butler on call!

Drs. Ho and Eng visited me twice everyday, once in the morning and again in the afternoon. I felt I was feeling good enough to be discharged. But, they noticed that I was peeing more. The nurses had been keeping count of my fluid input and output as diabetes insipidus, manifested by uncontrolled urination, was a common complication secondary to a pituitary surgery.

Dr. Ho was going away for the long weekend. It was going to be a public holiday Monday, 21 September, in Singapore to celebrate the end of Ramadan. He said that from his point of view, there was not going to be any more major complication. He ruled out any CSF (cerebrospinal fluid) leak. He said that he thought I was okay for discharge, but just to be sure, he recommended that I consume the 7-day guaranteed confinement issued by my insurance. He then said that he would leave my case to his neurosurgeon colleague, Dr. Alvin Hong. I thanked Dr. Ho, remarking that he had been great and agreed to see him at his clinic after I was discharged.

Day 5, Sunday, 20 Sep
I was walking about by this time and spending less time in bed. I was trying to tire myself hoping I could sleep unaided by the tablet.

I was starting to dread the nightfall as I imagined hours of turning in bed, finding no position that would make me get a full rest.

I was also peeing more, but Dr. Hong, the reliever, said that I was still okay and they wanted my brain to adjust naturally, hence, they were not giving me any medicine.

Day 6, Monday, 21 Sep
The day passed pretty much the same as the last one. Things had become a routine by this time. Let and I would Skype to see our kids online. I ached to go home.

Day 7, Tuesday, 22 Sep
The pathology staff came by 8am, and hourly afterwards until 10am to take blood samples for the hormone and liver function tests. I was given a glucose drink at 0 hour to check for growth hormone suppression.
At last I was going to be discharged! Dr. Eng gave me some take-home meds—Panadol for headache ad Imovaine for sleeplessness.

I was excited. I was still kind of weak, my nose was as blocked as it was from day 2, but I felt I was ready to get out of the hospital.

Let and I checked in to 2-star hotel. Hotel rates had doubled because of the Formula 1 (Grand Prix) event happening in SG on 24-26 Sep.

Day 8, Wednesday, 23 Sep
We went to see Drs. Eng and Ho at their clinics. Dr. Ho showed us the lab results. Gist of which was that we had attained the targeted growth hormone suppression level of less than 1 mIU/L. And although still rather early, my insulin growth factor (IGF 1) level was down from 352 to 212 ug/L. All other hormones (e.g., FSH, LH, and cortisol) remained within the normal ranges, meaning I had no need for any hormone replacement therapy. Thanks to Dr. Ho who did the job so cleanly yet thoroughly.

My growth hormone results (mIU/L) were:
• Pre-surgery, 15 Sep: 4.29
• Random, 0 hr: 0.70
• 1 hr: 0.23
• 2 hr: 0.96

Dr. Eng was sure that Dr. Ho would be happy to also see the results of the hormone tests. He said that IGF-1 test could be repeated after 2 months to get a more stable and accurate result. But, as for growth hormone, he is confident that we attained the clinically acceptable results for ascertaining that “cure” has been achieved. Symptomatically, soft tissue swelling around my fingers and toes had receded. It could also be that the water I previously retained was lost after my growth hormone levels went down.

Dr. Ho, for his part, showed us the histopathology report confirming that the tissues removed consisted of pituitary adenoma (tumor) which was growth-hormone secreting. He showed us a picture of the specimen. Dr. Ho was happy with the results. He repeated what he told me at the CCU that he thinks that he has cured me. He explained again how the operation went, and patiently answered our questions. We thanked him immensely and arranged to stay in contact by email for my next consultation.

After the consults with Drs. Eng and Ho, Let and I visited a high school friend of mine at their place in Choa Chu Kang, near East Jurong. We had dinner. I was full.

We were back at the hotel past 10pm. I was tired but again I could not sleep. I got up around 1am feeling nauseous. Then I started vomiting heavily. Afterwards, I took the sleeping pill to get some rest.

Day 9, Thursday, 24 Sep
I felt worse in the morning. I vomited again although I had practically nothing to throw up except water. I felt so weak that I asked Let to get me quickly to the hospital. Let phoned Dr. Ho and was instructed to bring me to the ER.

Dr. Ho came shortly after we arrived. My blood sample was taken for analysis. He confirmed with me first that what I was only vomiting, and that there was no fluid leaking from my nose. He then called Dr. Eng. I overheard him telling Dr. Eng that I could be having Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). Seeing how weak I was, Dr. Ho decided to have me re-admitted. I was again back at the ward.

I felt terrible, lethargic, spinning. The nurse injected something into the hep-lock for the dizziness. Dr. Eng came with the lab result. My sodium was at 120 mmol/l, normal is from 135-150 mmol/l. It was normal upon my discharge at 139, but suddenly dropped after 1 day causing the vomiting and dizziness.

He ordered me to restrict my fluid intake to a maximum of 800 ml per 24 hours. He also instructed treatment with i/v 3% saline 150 ml over 6 hours.

Day 10, Friday, 25 Sep
I felt that this time around was even more difficult. The saline drip was quite painful. The nurse had to reinsert the i/v line twice, making me have 4 insertions in total!

I realized that headache is far more pleasant than dizziness. I felt out of control whenever I was feeling dizzy.

Dr. Eng explained that I had a bit of diabetes insipidus (DI) 3 days after the operation. I then went on to have SIADH. My pituitary had been damaged a bit causing it to produce less ADH during the DI phase and then more ADH afterwards.

My brain, according to Dr. Ho, got a bit confused. The good thing was that it meant that ADH was not in short supply. And for a time, it was signaling my body to conserve water, resulting in salt dilution.

Day 11, Saturday, 26 Sep
We were scheduled to fly back to Manila at 5:40 pm. I was still nauseous upon waking up. I vomited again. But I resolved to be discharged. I managed to take a shower despite feeling giddy. I wanted to go home badly by now.

I was counting on the assurance of Dr. Eng that my sodium level would definitely come up so long as I was restricting my fluid intake.

Dr. Eng came early, and shortly after, Dr. Ho also arrived. They discussed my case and agreed that they expected nothing else to crop up. Because if there was any other complication, it would have manifested itself by this time, i.e., 10 days post-operation. They were confident that I was okay for discharge even if the sodium level had not yet normalized. It somehow stabilized at 119 mmol/l. Dr. Eng again assured me that it would normalize in 2 days.

By 1pm, we were off to Changi Airport. We were still rather early for our flight to Manila with ETD of 1740. Typhoon Ketsana, with local name “Ondoy,” was then inundating Manila. I was kept updated by posts made on Facebook. Rains had been non-stop since last night and floods were fast engulfing low-lying areas in Manila including our place, Taytay. Our Cebu Pacific flight was delayed as the aircraft was stalled by bad weather conditions in Manila. We finally boarded past 10pm, after long hours of waiting.

Day 12, Sunday, 27 Sep
We arrived NAIA half hour past 1am. I was feeling nauseous again so I asked for a wheelchair. We got out of the airport 2:30am and reached Ortigas by 3am. All roads to Cainta and Taytay were inaccessible. Trucks blocked the highway. Some parts of Ortigas Extension were flooded waist-deep. We were stranded!

It had been a very long wait at the airport. Now, there was nothing we could do but wait again until the floods subside and the roads clear. I had to spend the night in a hotel. Let had to leave me alone to fly to Cebu that night and report for work the following day. Good thing that my sister, who works in Laguna, was near the area as she was also stranded. She came to the hotel to accompany me. I was still feeling weak. It was likely that my sodium level was still low.

It was an ordeal alright. But I could not complain. I had no right to complain seeing the devastation brought on by the typhoon to the victims. The flooding was a nightmare! It made for good fiction. But seeing it claim lives and destroy so many homes was too much, making my recent experience pale in comparison to the kind of trial Ondoy suddenly brought to many Filipinos.

I am awed with gratitude. Our place, though right between Cainta and Taytay which were two of the most badly hit municipalities by Ondoy, was spared. I finally reached home the following day, 28 Sep, straight into the arms of my two children. I was home safe and cured. I have everything to thank God for.


with Dr. Ho Kee Hang - neurosurgeon


with Dr. Peter Eng - endocrinologist


with a Filipina nurse at Ward 10


taken at the lobby of Mount Elizabeth Hospital during my first discharge, 22 Sep 2009
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